Table 7

Investigation and management of borborygmi

Investigations	Potential results	Clinical management plan
Actions from history, medication and dietary assessment
History findings	Faecal loading	Plain AXR.
	Obstruction
	Mass	CT scan.
	Fibre excess/inadequacy	Refer for dietetic advice.
First line
Routine and additional blood tests	Abnormal results	Follow treatment for abnormal blood results (p. 2).
Glucose hydrogen methane breath test	SIBO	Management of SIBO (p. 27).
OGD and SI aspirate (p. 25) and biopsies	Enteric infection	Treat as recommended by microbiologist.
	SIBO	Management of SIBO (p. 27).
	Coeliac disease	Refer to coeliac clinic/dietitians/gastroenterology.
Carbohydrate challenge	Carbohydrate malabsorption	Management of carbohydrate malabsorption (p. 26).
Second line, if borborygmi are present in combination with other symptoms: flushing, abdominal pain, diarrhoea, wheezing, tachycardia or fluctuations in BP
Fasting gut hormones Chromogranin A+B Urinary 5-HIAA CT chest, abdomen, pelvis	Functioning NET eg, carcinoid syndrome or pancreatic NET	Discuss and refer urgently to the appropriate neuroendocrine MDT requesting an appointment within 2 weeks.
Plain AXR	Ileus/obstruction	This is an emergency. Discuss immediately with a GI surgeon and arrange urgent CT scan.
	Faecal loading	See management of constipation (p. 26).
Third line
Colonoscopy	Inflammatory bowel disease	Send stool culture. If mild or moderate, refer urgently to gastroenterology. If severe, this is an emergency. Discuss immediately with a gastroenterologist.
Fourth line
If normal investigations/no response to intervention		Reassure.

5HIAA, 5-hydroxyindole acetic acid; AXR, abdominal X-ray; CT, computerised tomography; GI, gastrointestinal; MDT, multidisciplinary team; NET, neuroendocrine tumour; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); SIBO, small intestinal bacterial overgrowth.